Altemeier Perineal Proctosigmoidectomy for Rectal Prolapse
Full-thickness rectal prolapse occurs when the rectum invaginates into the anal canal and beyond the anal sphincters. It is estimated to occur in 2.5 per 100,000 people, and most commonly affects women, particularly elderly women with other pelvic floor disorders. The only definitive treatment for rectal prolapse is surgery. In this case, we present an 80-year-old female with full-thickness rectal prolapse who underwent Altemeier proctosigmoidectomy. The redundant rectum is delivered and then excised through a transanal approach, and the proximal colon is sutured to the distal end of the rectum.
Full-thickness rectal prolapse is a debilitating condition that primarily effects women and occurs when the rectum invaginates into the anal canal and beyond the anal sphincters. The prevalence of full-thickness rectal prolapse in the general population is estimated 2.5 per 100,000 people, but it may be more common than reported, especially in aging individuals with other pelvic floor disorders.1, 2 Elderly patients are frequently bothered by rectal pain, feelings of a bulge, rectal and pelvic pressure, and incontinence; younger patients are more likely to report irregular bowel habits and incomplete stool evacuation.3
The only definitive management strategy for rectal prolapse is surgery. Perineal procedures are offered to frail patients at increased surgical risk, and the associated morbidity and mortality is low. We present the case of an 80-year-old female with symptomatic rectal prolapse who underwent a perineal operation for rectal prolapse: the Altemeier proctosigmoidectomy.3 The redundant rectum is delivered and then excised through a transanal approach, and the proximal colon is sutured to the distal end of the rectum. This procedure can be performed under regional anesthesia for individuals at risk for general anesthesia and intubation.
Focused history of patient
This patient was an 80-year-old wheelchair-bound female with a primary medical history of spina bifida of thoracolumbar region with hydrocephalus, brain aneurysm, gastroesophageal reflux disease (GERD), hypothyroidism due to Hashimoto’s disease, and neurogenic bladder. She first noticed rectal prolapse with defecation 2–3 years ago, and her symptoms had progressed prompting her to seek treatment. She reported severe discomfort and the feeling of sitting on a bulge. She described incomplete evacuation of stool, fecal incontinence, and mucus discharge per rectum. Her most bothersome symptoms were rectal pain and pelvic pressure. Her surgical history was notable for a hemorrhoidectomy and a total vaginal hysterectomy. She was taking levothyroxine, magnesium hydroxide, and vitamin supplements. She had no relevant family history. She was an American Society of Anaesthesiologists (ASA) class 3 given the systematic nature of her spina bifida and its involvement with her thoracic region. Her BMI was 21.48 kg/m2.
During our clinic examination we noted that despite her inability to ambulate due to spina bifida, she was very self-sufficient and could move herself to the exam table. Her vitals were within normal limits, and her abdominal examination was unremarkable.
On rectal exam, the sphincters were closed and her perineum was intact, and there was visible mucus discharge around the anus. On digital rectal exam, she had diminished rectal tone at rest and with squeeze. With Valsalva, she had 3–4 cm of circumferential full-thickness rectal prolapse while in the left lateral position. Vaginal examination was unremarkable with no signs of concomitant vaginal prolapse.
Neither radiologic imaging nor anorectal manometry testing was required given clear findings of rectal prolapse on examination.
In the absence of surgical repair, medical therapy and pelvic floor physical therapy can help manage bowel symptoms, but alone, cannot reverse rectal prolapse. If rectal prolapse is not repaired, patients will often report progressively worsening defecatory dysfunction with progressive fecal leakage and incomplete evacuation. There is some evidence to suggest that outcomes after surgery are worse the longer that surgery is delayed.4, 5
Options for treatment
Surgery is the only definitive management option for rectal prolapse. Prior to operative intervention, several steps can be taken to mitigate symptoms and hopefully, improve postoperative outcomes. Bowel consistency and frequency should be optimized with diet, fiber supplementation, laxatives, and/or stool softeners. The literature suggests higher recurrence rates after surgery in patients with Bristol Stool types 1 and 2 preoperatively.6 Pelvic floor physical therapy and biofeedback therapy preoperatively can help modify dyssynergic behaviors associated with rectal prolapse.7-10 Medical evidence to support routine use of pelvic floor rehabilitation for rectal prolapse is lacking, but in pelvic organ prolapse, this is a common evidence-based practice. Finally, because this population tends to be elderly, we also advocate for preoperative optimization of patients’ nutrition and exercise status.
The repair is done through either an abdominal or perineal approach. Although there are over 100 types of abdominal and perineal procedures, there is no consensus on which intervention is best suited for each individual, and the decision around which approach to take is best made via a shared decision-making process.11 Abdominal approaches are generally thought to be more durable than perineal approaches (abdominal recurrence rates around 8–15% versus around 20–40% in perineal repairs ), 3, 1214 but are associated with longer operative times and time under anesthesia.15-18 For very frail patients or patients with a history of multiple abdominal/pelvic operations, perineal approaches offer an effective, safe option with favorable postoperative functional outcomes.14, 15, 19 Importantly, age alone should not dictate the approach as with minimally invasive techniques, even elderly patients can safely undergo abdominal repairs.17, 20
Rationale for treatment
Our patient had rectal prolapse for 2–3 years, with worsening symptoms that had increasingly impacted her quality of life. She had been enrolled in pelvic floor physical therapy, had optimized her stool consistency, but was still having ongoing bothersome symptoms. A perineal operation was offered to her given her frailty.
The most common perineal repairs for rectal prolapse are the Delorme mucosal sleeve resection and Altemeier proctosigmoidectomy. In the Delorme repair, just the mucosal sleeve of the prolapsed rectum is resected; this approach is favored for patients with short segment rectal prolapse.3 In the Altemeier repair, the prolapsed rectum is pulled out of the anal canal, the colon is divided and resected, and a colorectal/coloanal anastomosis is created.3 Our patient underwent an Altemeier procedure given the length of her prolapse. The goals were to alleviate her pain and the sensation of sitting on a bulge, and to improve her obstructed defecation symptoms.
Perineal operations for rectal prolapse are well suited to frail, elderly patients. Perineal repairs involve a much shorter period of anesthesia and can be done under spinal or local anesthetic. The trade-off with abdominal operations is a higher recurrence rate. There are no current definitive guidelines that dictate which patients are most likely to benefit from perineal operations.4 For the very frail or medically complex, the decision may be clear; for patients in whom the decision is less clear, we suggest a shared decision-making model.
One final consideration is whether the patient had a prior sigmoid or rectal resection. In this circumstance, an Altemeier proctosigmoidectomy4 may result in an ischemic segment of bowel and should be avoided. The most common complications after perineal prolapse repair include urinary tract infections or retention, anastomotic bleeding, pelvic abscess, and anastomotic leak, although the overall morbidity rate is low.3, 21
This is the case of an 80-year-old woman that underwent a perineal proctectomy to treat full-thickness rectal prolapse.
The patient was placed in the lithotomy position with the surgeon and assistant between the legs. A Lone Starr (CooperSurgical®, CT) retractor was used to evert the anus and reveal the dentate line. Gentle traction with Babcock forceps helped expose the full extent of the rectal prolapse. The rectum was scored circumferentially to mark the distal resection margin about 2–4 cm proximal to the dentate line. Local anesthesia with epinephrine was injected, and electrocautery was used to divide the full thickness of the rectum until the mesentery was identified. The mesentery was then divided with an energy device. The pouch of Douglas was opened to access the abdominal cavity and ensure there are no redundant loops of sigmoid colon in the pelvis. This allows for accurate assessment of what the most proximal resection margin should be; the proximal margin is ideally a diverticula-free segment that allows for a tension-free anastomosis without unnecessary redundancy.
Prior to completing the resection, we performed a posterior levatorplasty to tighten the pelvic floor muscles with interrupted 2-0 PDS sutures. The pouch of Douglas was closed. We next prepared for the anastomosis. The proximal margin was divided, and as it was divided, four absorbable stay sutures were placed in the four quadrants. It is important to ensure that these are full-thickness bites to both the proximal colon and distal rectum. Next, intervening bisecting sutures were placed. Placing the sutures in a staged circumferential manner helps manage any difference in the luminal caliber of the proximal bowel and the distal rectum. Additional in-between sutures were placed to ensure the two ends of the bowel wall were juxtaposed. Any gaps in the continuity of the mucosa were closed with additional sutures. Finally, all of the sutures were tied, and the rectum was reduced. The length of the rectum resected in this case was approximately 8–9 cm. The total operative time was 89 minutes.
She was discharged after a three-day hospital stay because of challenges coordinating transport, which was a bit longer than our institutional average after perineal rectal prolapse repair. She did not experience any postoperative complications. At her 4-week post-op visit, she was recovering well. She reported that the feelings of pain and bulging had resolved. Though there was no change in her fecal incontinence, she did report improved evacuation. She reported a Patient Global Impression of Change score of 7 (“A great deal better and a considerable improvement that has made all the difference”).
At one month post perineal proctectomy, persistent fecal accidents are not unexpected. We had discussed with her preoperatively that because of her long-standing prolapse and baseline incontinence, she may have some ongoing incontinence postoperatively. Expectation setting with patients is important in rectal prolapse surgery, and our discussions with her preoperatively may partially explain why her PGIC score is overwhelmingly positive despite persistent fecal incontinence.
Once her anastomosis had healed, she resumed pelvic floor exercises, and we continue to follow her progress as an evaluation of postoperative bowel function is best measured after 3 months.
No special equipment was used in this case.
Rectal prolapse can cause bothersome symptoms and negatively impact a patient’s quality of life. While abdominal rectal prolapse repair operations are arguably more durable, perineal operations can be performed safely in elderly, frail patients and provide symptomatic relief and measurable improvement in quality of life. We advocate for shared decision making and realistic expectations to achieve patient satisfaction.
The authors have no disclosures.
Statement of Consent
The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.
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